Aims In Northern England, a multicentre regional endoscopy training initiative – the Northern Endoscopy Training Academy (NETA) – was established in September 2022 and provides novice gastroscopy trainees with a 4-week immersion block of 20 dedicated training lists (DTLs) at one of four immersion centres within the first 20 weeks of beginning training, plus regular weekly DTLs at their hospital site until they achieve criteria for certification. Our aim was to measure the impact on skill acquisition and time to achieve minimum KPIs for JAG certification [1].

Introduction The prevalence of chronic pancreatitis in post mortem studies is between 6–12%. We previously studied over 1800 all-comers to secondary care gastroenterology and found 14.4% had low faecal elastase-1 (FEL-1) suggestive of exocrine pancreatic insufficiency (EPI). We sought to investigate if there were similar rates in primary care. Method A retrospective analysis of primary care patients tested for EPI between 2009–13 was performed. FEL-1 <200 was considered abnormal. Demographics, indication, co-morbidities and response to Creon were noted. Patients were excluded if the test originated in secondary care. Pancreatic imaging results were noted. Logistic regression helped determine if co morbidity or symptom could predict EPI. Comparisons were made with the secondary care cohort. Results 168 primary care patients and 1887 ssecondary care patients were identified. The mean age in primary care was 59.74 (SD 16.26, 98 female) cf secondary care mean age 51.60 (SD 16.91, 1144 female) p < 0.0001. The most frequent indications to test in primary care were diarrhoea (60.1% 101/168), weight loss (14.9% 25/168) and abdominal pain (13.1% 22/168). In secondary care the most common indications were diarrhoea (68.4% 1252/1887), abdominal pain (20.0% 378/1887) and weight loss (6.6% 125/1887). The overall prevalence of EPI in primary care was 20.2% (FEL-1 <200) and 11.9% (FEL <100). In secondary care the overall prevalence of EPI was 14.4% (FEL-1 <200) and 8.6% (FEL-1 <100). In primary care patients with weight loss, abdominal pain and diarrhoea the rates of FEL-1 <200 were 28.0% (7/25), 18.2% (4/22) and 16.8% (17/101) respectively. 79.4% (27/34) of primary care patients with FEL-1 <200 had abdominal imaging (CT/MRI/USS); pancreatic pathology was detected in 59.6% (16/27). 86.8% of secondary care patients with FEL-1 <200 had imaging; 38.1% (90/236) had pathology (p = 0.04). Weight loss and steatorrhoea were significantly associated with FEL-1 <200 using binary logistic regression (p < 0.05). Diabetes mellitus, coeliac disease and excess alcohol consumption were strongly associated with pancreatic insufficiency (p < 0.05). 76.5% (26/34) patients had documented pancreatic enzyme supplementation, of which 80.7% (21/26) reported symptomatic relief. 7.7% reported no benefit and 11.5% were unable to tell. Conclusion This is the first primary care study reporting a prevalence of exocrine pancreatic insufficiency (20.2%). Primary care physicians are correctly identifying patients for testing presenting with weight loss and steatorrhoea, as well as considering the associations of diabetes, coeliac disease and excess alcohol. Imaging and symptomatic benefit (from Creon) supports their diagnosis in almost 60% and 80% respectively. Disclosure of interest None Declared.

Introduction Post-mortem studies suggest that chronic pancreatitis is present in 6–12% of the population, yet the diagnosis of chronic pancreatitis is infrequent. We hypothesised that previously undetected pancreatic exocrine insufficiency is seen in unselected patients referred to secondary care gastroenterology clinics. Methods A multicentre retrospective analysis of all gastroenterology patients tested for faecal elastase (FEL-1) between 2009–13 was performed. In Sheffield and Middlesbrough a FEL-1 <200 μg/g was defined as abnormal. Demographics, indication, co-morbidities and response to enzyme supplementation were recorded. Additionally, the findings of abdominal imaging were recorded. Prevalence of low FEL-1 was compared between the two centres (Fishers exact test). Binary logistic regression was used to determine if comorbidities could predict pancreatic insufficiency. Results 1887 patients (mean age 51.6, SD 16.91, 1144 females) were included. Sheffield’s group contained 1350 patients (mean age 49.1, SD 16.37, 857 females), and Middlesbrough’s 537 (mean age 57.9, SD 16.60, 287 female). The most common indication to test FEL-1 was diarrhoea (n = 1252), followed by abdominal pain (n = 378) and weight loss (n = 125). The overall prevalence of low FEL-1 was 11.4% (Sheffield 11.0% vs. Middlesbrough 22.9% p < 0.0001). 13.7% (n = 171/1252) of patients with diarrhoea as the predominant symptom had FEL-1 <200. Of those with abdominal pain and weight loss 12.4% (n = 47/378) and 27.2% (n = 35/125) had low FEL-1 respectively. 86.8% (n = 236) of patients with low FEL-1 had abdominal imaging, (MRI, CT or US). 50% of imaging was normal (n = 136), 33.1% (n = 90) demonstrated pancreatic pathology consistent with either chronic pancreatitis or malignancy. Binary logistical regression showed FEL-1 <200 was strongly associated with excess alcohol intake, diabetes mellitus, intrinsic pancreatic disease (malignant or non-malignant) and HIV infection (p < 0.0001). 79% (n = 128) of patients treated with pancreatic enzyme supplementation subjectively reported benefit from therapy. 12.3% (n = 20) had no benefit and in 8.6% (n = 14) it was not possible to assess benefit from medical records. Conclusion This is the largest study to report detection of exocrine pancreatic disease in unselected gastroenterology clinics. Exocrine pancreatic insufficiency is strongly associated with diabetes mellitus, intrinsic pancreatic disease, high alcohol intake and HIV. Creon provides symptomatic benefit for those with pancreatic insufficiency, but further work is needed to establish appropriate dosage of enzyme supplementation. Clinicians should have a low threshold for checking FEL-1. Disclosure of Interest None Declared.

Introduction Positron emission tomography (PET) measures metabolic changes at a cellular level enabling detection of early stage disease. Incidental 2-deoxy-[18FF]fluoro-2-D-glucose (FDG) colonic uptake is detected in 1.3–3% of patients with up to a third resulting in false positive results.1 Follow-up endoscopy is recommended to further distinguish these FDG avid lesions.2 Cancer detection rates of 7.8–18.9% have been quoted in various studies.1,3 Our aim was to evaluate colonic FDG avid lesions on PET by endoscopy. Methods An analysis of prospectively collected database of all patients (n = 1564) who had PET for various malignancy between January 2011 to September 2013 was performed. Results Fifty-nine (3.77%) patients had focal colonic FDG uptake and 45 (2.87%) patients went on to have colonoscopy. Indications for PET CT for those undergoing endoscopy was lung carcinoma (22), gastrointestinal carcinoma (10), laryngeal carcinoma (7) and lymphoma (6). Median age was 64 with a male preponderance (2.5:1) Location on PET CT was categorised to sigmoid (23), rectal (9), anorectal (4), caecal (3), hepatic flexure (2), transverse (1), splenic flexure (1), ascending (1) and descending (1). Findings on endoscopy ranged from polyps (22), normal (9), diverticulosis (8), sigmoid cancer (4), caecal cancer (1) and colitis (1). In total, out of the all patients who had endoscopy, 20 (44.4%) were found to have low grade tubullovillous adenomas, 5 (11.1%) had cancer, whilst 2 (4.4%) had hyperplastic polyps on histology. Conclusion These findings are in keeping with other series and suggest that it makes sense only to carry on with current practice of following up these hot spots with endoscopy. References 1 Israel O, Yefremov N, Bar-Shalom R, Kagana O, Frenkel A, Keidar Z, et al. PET/CT detection of unexpected gastrointestinal foci of 18F-FDG uptake: incidence, localization patterns, and clinical significance. J Nucl Med 2005;46:758–762 2 Tatlidil R, Jadvar H, Bading JR, Conti PS. Incidental colonic fluorodeoxyglucose uptake: correlation with colonoscopic and histopathologic findings. Radiology 2002;224:783–787 3 Putora PM, Muller J, Borovicka J, Plasswilm L, Schmidt F. Relevance of incidental colorectal FDG-PET/CT-enhanced lesions. Onkologie 2013;36(4):200–4 Disclosure of Interest None Declared.

Introduction “Immune activation” has been described in the mucosa of IBS-D patients which Mesalazine (M) could suppress. Our main aim was to compare the effect of M versus placebo (P) on stool frequency. Secondary endpoints were abdominal pain, stool consistency and satisfactory relief of IBS symptoms. Methods All patients were required to have daily stool frequency of ≥3/day for more than 2 days/week for 2 weeks and stool consistency of ≥25% type 5–7 and ≤25% type 1–2 according to the Bristol Stool Form Scale. Subjects were randomised to either 2g M/ P for a week, to increase to 2 g twice/day for remaining 11 weeks if tolerated. All participants completed a 12-week stool diary. Since we expected M would require >2 months exert its effect, all primary and secondary outcomes were based on the stool diary completed during week 11–12. Satisfactory relief of IBS symptoms was defined as answering ‘yes’ to weeks 11 and 12 of the stool diary Results 136 subjects with IBS-D, meeting the Rome III criteria, were randomised to the 2 groups. Mean (SD) age was 47.1 (13.5) years in P and 42.6 (15.2). Treatment compliance for P and M were similar, 59% and 58% respectively. Analysis by intention to treat showed M did not improve bowel frequency, abdominal pain and stool consistency compared to P during week 11–12. Treatment did not affect satisfactory relief of IBS symptoms, HAD, PHQ15 and EQ-5D VAS scores compared to P. See table below for results. Conclusion This study did not show any clinically meaningful benefit or harm of M compared to P in this group of IBS-D patients. We need better phenotyping/ biomarkers for IBS patients to allow targeting of effective treatments. Disclosure of Interest C. Lam: None Declared, W. Tan: None Declared, M. Leighton: None Declared, J. Williams: None Declared, A. Agrawal: None Declared, S. Sen: None Declared, S. Foley: None Declared, M. Rutter: None Declared, A. Ramadas: None Declared, P. Whorwell Grant/research support from: Danone, Almirall, Shire, Boehringer Ingelheim UK, Sucampo, Saliz, Chr-Hansen and Norgine, Consultant for: Danone, Almirall, Shire, Boehringer Ingelheim UK, Sucampo, Saliz, Chr-Hansen and Norgine, A. Montgomery: None Declared, R. Spiller Grant/research support from: Lessaffre, Ironwood, Consultant for: Almirall, Astellas, Danone and Sanofi, Conflict with: free drug for clinical trial from Norgine.

IntroductionThere is enormous variability in the referral rates for IBS from GPs and this relates to patient and physician factors.1 IBS patients tend to wait longer for appointments and hence a standardised algorithm which includes faecal calprotectin (FC) might aid in the rapid assessment of IBS in secondary care. FC has been shown to consistently differentiate IBS from IBD because it has excellent negative predictive value in excluding organic pathology.2MethodsTo assess the efficacy of diagnostic algorithm (using FC) for assessment of IBS in a pilot study using patients already referred to hospital GI clinics. Patients were included if the GP suspected IBS (age group 18–50),without alarm symptoms (weight loss, rectal bleeding etc) at time of referral. Initial assessment was in a nurse-led clinic using a standardised algorithm consisting of questionnaire and baseline investigations (FC, FBC, ESR, CRP, albumin, IgA and TTG). FC level < 100 mcg/g was considered normal.3 4 week review was undertaken by a doctor and those with abnormal results were transferred to the GI clinic. 1-year assessment was undertaken on all study patients, reviewing final diagnosis and hospital visits. Clinical diagnosis by nurse and doctor before results of FC and blood tests were compared. Co-primary end-points were the positive predictive value (PPV) of the algorithm in diagnosing IBS and the added benefit of FC in excluding organic pathology.Results54 patients were recruited and 51 attended the 4-week follow up. 49/54 (90%) had complete 1-year follow-up data. Reason for GP referral was ‘uncertain diagnosis’ in 37/54 (69%) and ‘confirmation of IBS’ in 17/54 (31%) patients. There was 95% concordance between nurse and doctor in the clinical diagnosis of IBS (blinded to blood results and FC) based on Rome criteria. 44/54 (81%) were diagnosed as IBS at 4-week review and none had evidence of organic pathology at 1 year. Non-IBS diagnosis 5/54 (9%) included 3 IBD and 2 Coeliacs. Median FC levels in the IBS and non-IBS groups were 19.5 and 1105 respectively (p=0.0001). Two patients in the IBS group were re-referred within 1-year (final diagnosis IBS). PPV of the algorithm in diagnosing IBS was 100% without FC, but FC clearly identified the IBD patients and a normal level (96% −ve predictive value) provided valuable reassurance.ConclusionThis diagnostic algorithm is useful for a nurse-led clinic for assessment of suspected IBS referred to hospital, and FC measurements improve the diagnostic confidence of nurses and doctors, and removes the need for endoscopic investigation in patients under 50.